Citi Benefits Handbook
The Oxford Health Plans PPO at a Glance
Note: For in-network covered expenses, the plan pays a percentage of discounted rates while for out-of-network charges, the plan pays a percentage of the maximum allowed amount (MAA). See the Glossary section for a definition of MAA, which is sometimes referred to as "Recognized Charges."
Type of service
In-network
Out-of-network
Annual deductible
  • Individual
  • $500
  • $1,500
  • Maximum per family
  • $1,000
  • $3,000
Annual medical out-of-pocket maximum (includes medical deductible, medical coinsurance, and medical copayments)
Note: There is a separate annual out-of-pocket maximum for prescription drugs.
  • Individual
  • $3,000
  • $6,000
  • Maximum per family
  • $6,000
  • $12,000
Lifetime maximum
  • None
  • None
Professional care (in office)
  • PCP visits
  • 80% after deductible2
  • 60% of MAA after deductible2
  • Specialist visits
  • 80% after deductible2
  • 60% of MAA after deductible2
  • Allergy treatment
  • 80% after deductible2 for the first office visit; 100% for each additional injection if office visit fee is not charged
  • 60% of MAA after deductible2
Preventive care (subject to frequency limits)
  • Well-adult visits
  • 100%, not subject to deductible
  • 100%, not subject to deductible, up to $250 maximum1, then covered at 60% of MAA, not subject to deductible
  • Well-child visits
  • 100%, not subject to deductible
  • 100%, not subject to deductible, up to $250 maximum1, then covered at 60% of MAA, not subject to deductible
  • Adult and Child Routine Immunizations
  • 100%, not subject to deductible
  • 60% of MAA, not subject to deductible
  • Routine cancer screenings (Pap smear, mammography, sigmoidoscopy, colonoscopy, PSA screening)
  • 100%, not subject to deductible
  • 100%, not subject to deductible, up to $250 maximum1, then covered at 60% of MAA, not subject to deductible
  • Contraceptive devices
  • 100%, not subject to deductible, for diaphragms and Mirena, an implantable device and at least one in each category of the other applicable forms of contraception in the FDA Birth Control Guide that are not covered under the Citi prescription drug program (see "Preventive Care"). All other implantable devices will be covered at 80% after deductible1
  • 60% of MAA after deductible2
  • Voluntary sterilization — including tubal ligation, sterilization implants and surgical sterilizations
  • 100%, not subject to deductible. Male sterilization services (e.g., vasectomies) are covered at 80% after deductible1
  • 60% of MAA after deductible1
Routine care (subject to frequency limits)
    • Routine vision exams
    • In- and out-of-network combined limit: one exam per calendar year
  • 100%, not subject to deductible
  • 100%, not subject to deductible, up to $250 maximum1, then covered at 60% of MAA, not subject to deductible
    • Routine hearing exams
    • In- and out-of-network combined limit: one exam per calendar year
  • 100%, not subject to deductible
  • 100%, not subject to deductible, up to $250 maximum1, then covered at 60% of MAA, not subject to deductible
Hospital inpatient and outpatient
  • Semiprivate room and board, doctor's charges, radiology, lab, X-ray, and surgical care
  • 80% after deductible2; precertification required for hospitalization and certain outpatient procedures
  • 60% of MAA after deductible2; precertification required for hospitalization and certain outpatient procedures
Non-routine outpatient
  • Radiology, lab, and X-ray
  • 100%, not subject to deductible if performed in an office setting (or in-network facility for lab services); 80% after deductible2 if performed in another place of service; precertification required for certain outpatient procedures
  • 60% of MAA after deductible2; precertification is required for certain outpatient procedures
Maternity care
  • Physician office visit
  • 80% after deductible2
  • 60% of MAA after deductible2
  • Hospital delivery
  • 80% after deductible2
  • Precertification required if admission exceeds 48 hours for a vaginal delivery or 96 hours for a cesarean section delivery
  • 60% of MAA after deductible2
  • Precertification required if admission exceeds 48 hours for a vaginal delivery or 96 hours for a cesarean section delivery
Emergency care (no coverage if not a true emergency)
  • Hospital emergency room (includes emergency room facility and professional services provided in the emergency room)
  • 80% after deductible2 precertification is required for hospitalization and certain outpatient procedures
  • 80% of MAA after deductible2 precertification is required for hospitalization and certain outpatient procedures
  • Urgent care facility
  • 80% after deductible2
  • 80% of MAA after deductible2
Emergency Transportation Services (no coverage when used as routine transportation to receive inpatient or outpatient services)
 
100%, not subject to the deductible; for transport to and from the nearest medical facility qualified to give the required treatment; pre-certification required for inter-facility transfers
100%, not subject to the deductible; for transport to and from the nearest medical facility qualified to give the required treatment; pre-certification required for inter-facility transfers
Outpatient short-term rehabilitation
  • Physical/occupational/speech therapy (combined): Limited to 90 visits a year for physical/occupational/speech therapy in-network and out-of-network combined.
  • 80% after deductible2
  • 60% after deductible2 for approved visits over plan limits
  • 60% of MAA after deductible2,
  • 50% of MAA after deductible2 for approved visits over plan limits
  • Chiropractic therapy, up to 20 visits per year for in-network and out-of-network services combined; precertification required
  • 80% after deductible2
  • 60% of MAA after deductible2
Other services
  • Durable medical equipment (includes orthotics/prosthetics and appliances)
  • 80% after deductible2; precertification required for equipment with a purchase or cumulative rental cost of $500 or more
  • 60% of MAA after deductible2; precertification required for equipment with a purchase or cumulative rental cost of $500 or more
  • Private-duty nursing and home health care
  • 80% after deductible2, limited to 200 visits annually for in-network and out-of-network services combined; precertification required
  • 60% of MAA after deductible2, limited to 200 visits annually for in-network and out-of-network services combined; precertification required
  • Hospice
  • 80after deductible2; precertification required
  • 60% of MAA after deductible2; precertification required
  • Skilled nursing facility
  • 80% after deductible2 (limited to 120 days annually for in-network and out-of-network services combined); precertification required
  • 60% of MAA after deductible2 (limited to 120 days annually for in-network and out-of-network services combined); precertification required
  • Infertility treatments
  • Covered up to a $24,000 family lifetime medical maximum combined in-network and out-of-network. The lifetime maximum will be coordinated among all non-HMO/PPO medical options.
  • 80% after deductible2 up to the family lifetime maximum; precertification required
  • Covered up to a $24,000 family lifetime medical maximum combined in-network and out-of-network. The lifetime maximum will be coordinated among all non-HMO/PPO medical options.
  • 60% after deductible2 up to the family lifetime maximum; precertification required
Prescription drugs (see the Prescription Drugs section)
Mental health and substance abuse (refer to "Mental.")
1 Combined maximum benefit applies to well-adult visits, well-child visits, routine cancer screenings, routine hearing, and routine vision. The maximum is measured on a calendar year basis.
2 The plan will pay this percentage of the cost after you first pay the full deductible of the plan. The deductible can be paid with after-tax dollars, such as cash or check, or with before-tax dollars if you have available funds in a Health Care Spending Account(HCSA).
These tables are intended as a brief summary of benefits. Not all covered services, exclusions, and limitations are shown. For additional information and/or clarification of benefits, see "Covered Services and Supplies" and "Exclusions and Limitations."